Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics

Clinical Chemistry and Laboratory Medicine

Volumn 47, Issue 2, 2009, Pages 143-153

  Lippi, Giuseppe ^a,b,c,j   Blanckaert, Norbert ^b,d   Bonini, Pierangelo ^b,c,e   Green, Sol ^b,f   Kitchen, Steve ^b,g   Palicka, Vladimir ^b,h   Vassault, Anne J ^b,i   Mattiuzzi, Camilla ^j   Plebani, Mario ^c,k  

^a UNIVERSITY OF VERONA   (Italy)

^b EPSC European Preanalytical Scientific Committee ^*  (Italy)

^c International Federation of Clinical Chemistry Working Group on Patient's Safety   (Italy)

^d UNIVERSITY HOSPITALS LEUVEN   (Belgium)

^e VITA SALUTE SAN RAFFAELE UNIVERSITY   (Italy)

^f BD Diagnostics Preanalytical Systems   (United States)

^g ROYAL HALLAMSHIRE HOSPITAL   (United Kingdom)

^h UNIVERSITY HOSPITAL HRADEC KRALOVE   (Czech Republic)

ⁱ HÔPITAL NECKER ENFANTS MALADES   (France)

^j UNIVERSITY HOSPITAL OF VERONA   (Italy)

^k UNIVERSITY OF PADOVA   (Italy)

more..

Author keywords

Errors; Laboratory medicine; Misidentification; Patient identification; Patient safety

Indexed keywords

ACCURACY; CLINICAL DECISION MAKING; CLINICAL LABORATORY; CONFERENCE PAPER; DIAGNOSTIC ERROR; HEALTH CARE; HUMAN; IDENTIFICATION KEY; INFORMATION TECHNOLOGY; LABORATORY AUTOMATION; LABORATORY DIAGNOSIS; LABORATORY TEST; MONITORING; OUTCOME ASSESSMENT; PATIENT CODING; PATIENT IDENTIFICATION; PATIENT INFORMATION; PRACTICE GUIDELINE; PREVALENCE; PREVENTION; PRIORITY JOURNAL; SAMPLE; WORK ENVIRONMENT;

AUTOMATIC DATA PROCESSING; DIAGNOSTIC ERRORS; HUMANS; LABORATORY TECHNIQUES AND PROCEDURES; PATHOLOGY, CLINICAL; PATIENT IDENTIFICATION SYSTEMS; SENSITIVITY AND SPECIFICITY; SPECIMEN HANDLING;

EID: 59849109926     PISSN: 14346621     EISSN: 14374331     Source Type: Journal    
DOI: 10.1515/CCLM.2009.045     Document Type: Conference Paper

References (68)

1. Kohn KT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press, 1999.
2. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability in the eye of the reviewer. J Am Med Assoc 2001;25:415-20.
3. National Coordinating Council for Medication Error Reporting and Prevention. What is a medication error? http://www.nccmerp.org/aboutMedErrors. html. Accessed 16 July 2008.
4. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
5. Sandars J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract 2003;20:231-6.
6. Plebani M. Errors in clinical laboratories or errors in laboratory medicine? Clin Chem Lab Med 2006;44:750-9.
7. Lippi G, Guidi GC, Mattiuzzi C, Plebani M. Preanalytical variability: the dark side of the moon in laboratory testing. Clin Chem Lab Med 2006;44:358-65.
8. Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem 2002;48:691-8.
9. Bonini P, Alpert N, Luzzana M, Rubin R. Guidelines for the identification and distribution of patient samples in the medical laboratory. Recommendation of the European Committee for Clinical Laboratory Standards (ECCLS) and approved document of the International Federation of Clinical Chemistry (IFCC). J Automat Chem 1994;16:25-32.
10. Sanna A, Wilikens M, Borio di Tigliole A, Klein G, Bonini P. Safety procedures for identification of patients and related object - CEN TC 251 Technical Report N 00-049-2000. Available at: www.centc251.org. Accessed 16 July 2008.
11. Osborne J, Blais K, Hayes JS. Nurses' perceptions: when is it a medication error? J Nurs Adm 1999;29:33-8.
12. Shulman IA, Lohr K, Derdiarian AK, Picukaric JM. Monitoring transfusionist practices: a strategy for improving transfusion safety. Transfusion 1994;34:11-5.
13. Joint Commission on Accreditation of Healthcare Organizations. Sentinel event statistics. Available at: http://www.jointcommission.org/SentinelEvents/ Statistics/. Accessed 16 July 2008.
14. Mannos D. NCPS patient misidentification study: a summary of root cause analyses. VA NCPS topics in patient safety. Washington, DC: United States Department of Veterans Affairs, June-July 2003. Available at: www.va.gov/ncps/TIPS/Docs/TIPS-Jul03.doc. Accessed 16 July 2008.
15. National Patient Safety Agency. Standardising wristbands improves patient safety. Available at: http://www.npsa.nhs.uk/site/media/documents/1440-Safer- Patient-Identification-SPN.pdf. Accessed 16 July 2008.
16. Bittle MJ, Charache P, Wassilchalk DM. Registration-associated patient misidentification in an academic medical center: causes and corrections. Jt Comm J Qual Patient Saf 2007;33:25-33.
17. Simpson JH, Lynch R, Grant J, Alroomi L. Reducing medication errors within the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2004;89:F480-2.
18. Suresh G, Horbar JD, Plsek P, Gray J, Edwards WH, Shiono PH, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004;113:1609-18.
19. Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion 1992;32:601-6.
20. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990;30:583-90.
21. Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion 2002;32:601-8.
22. Dzik WH, Murphy MF, Andreu G, Heddle N, Hogman C, Kekomaki R, et al. for the Biomedical Excellence for Safer Transfusion (BEST) Working Party of the International Society for Blood Transfusion. An international study of the performance of sample collection from patients. Vox Sang 2003;85:40-7.
23. Stainsby D, Russell J, Cohen H, Lilleyman J. Reducing adverse events in blood transfusion. Br J Haematol 2005;131:8-12.
24. Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clin Lab Med 2004;24:979-96.
25. Renner SW, Howanitz PJ, Bachner P. Wristband identification errors reporting in 712 hospitals: a College of American Pathologists Q-Probe study of quality issues in transfusion practice. Arch Pathol Lab Med 1993;117:573-7.
26. Howanitz PJ, Renner SW, Walsh MK. Continuous wristband monitoring over 2 years decreases identification errors: a College of American Pathologists Q-Tracks study. Arch Pathol Lab Med 2002;126:809-15.
27. Khoury M, Burnett L, Mackay MA. Error rates in Australian chemical pathology laboratories. Med J Aust 1996;165:128-30.
28. Valenstein P, Meier F. Outpatient order accuracy. A College of American Pathologists Q-Probes study of requisition order entry accuracy in 660 institutions. Arch Pathol Lab Med 1999;123:1145-50.
29. Lippi G, Guidi GC. Risk management in the preanalytical phase of laboratory testing. Clin Chem Lab Med 2007;45:720-7.
30. Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem 2007;53:1338-42.
31. College of American Pathologists, Valenstein PN, Raab SS, Walsh MK. Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Arch Pathol Lab Med 2006;130:1106-13.
32. Lee AC, Leung M, So KT. Managing patients with identical names in the same ward. Int J Health Care Qual Assur Inc Leadersh Health Serv 2005;18:15-23.
33. Hughes D. Root cause analysis: bridging the gap between ideas and execution. VA NCPS topics in patient safety. Washington, DC: United States Department of Veterans Affairs, November-December 2006. Available at: http://www.va.gov/ncps/TIPS/Docs/TIPS-NovDec06.pdf. Accessed 16 July 2008.
34. Gray JE, Suresh G, Ursprung R, Edwards WH, Nickerson J, Shiono PH, et al. Patient misidentification in the neonatal intensive care unit: quantification of risk. Pediatrics 2006;117:e43-7.
35. Health informatics. Safety procedures for identification of patients and related objects. PD CEN/TR 15299:2006.
36. Robillard P, Itaj NK, Corriveau P. ABO incompatible transfusions, acute and delayed hemolytic transfusion reactions in the Quebec hemovigilance system-year 2000. Transfusion 2002;42(Suppl):25S.
37. Andreu G, Morel P, Forestier F, Debeir J, Rebibo D, Janvier G, et al. Hemovigilance network in France: organization and analysis of immediate transfusion incident reports from 1994 to 1998. Transfusion 2002;42:1356-64.
38. Nutting PA, Main DS, Fischer PM, Stull TM, Pontious M, Seifert M Jr, et al. Toward optimal laboratory use. Problems in laboratory testing in primary care. J Am Med Assoc 1996;275:635-9.
39. Plebani M, Carraro P. Mistakes in a stat laboratory: types and frequency. Clin Chem 1997;43:1348-51.
40. Hofgärtner WT, Tait JF. Frequency of problems during clinical molecular-genetic testing. Am J Clin Pathol 1999;112:14-21.
41. Nicholls MD. Transfusion: morbidity and mortality. Anaesth Intensive Care 1993;21:15-9.
42. Joint Commission on Accreditation of Healthcare Organizations. 2008 National patient safety goals. Available at: http://www.jointcommission.org/ PatientSafety/NationalPatientSafetyGoals/08-amb-npsgs.htm. Accessed 16 July 2008.
43. Leape LL, Berwick DM. Safe health care: are we up to it? Br Med J 2000;320:725-6.
44. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med 1989;320:53-6.
45. Longo DR, Hewett JE, Ge B, Schubert S. The long road to patient safety: a status report on patient safety systems. J Am Med Assoc 2005;294:2858-65.
46. Reason J. Human error: models and management. Br Med J 2000;320:768-70.
47. Signori C, Ceriotti F, Sanna A, Plebani M, Messeri G, Ottomano C, et al. Process and risk analysis to reduce errors in clinical laboratories. Clin Chem Lab Med 2007;45:742-8.
48. Plebani M, Ceriotti F, Messeri G, Ottomano C, Pansini N, Bonini P. Laboratory network of excellence: enhancing patient safety and service effectiveness. Clin Chem Lab Med 2006;44:150-60.
49. Bologna LJ, Mutter M. Life after phlebotomy deployment: reducing major patient and specimen identification errors. J Healthc Inf Manag 2002;16:65-70.
50. Joint Commission on Accreditation of Healthcare Organizations. Patient safety solutions. 2007. Available at: http://www.jcipatientsafety.org/ fpdf presskit/PS-Solution2.pdf. Accessed 16 July 2008.
51. Food and Drug Administration. Strategies to reduce medication errors. Available at: http://www.fda.gov/fdac/features/2003/303-meds.html. Accessed 16 July 2008.
52. Killeen JP, Chan TC, Jones K, Guss DA. Impact of bar coding technology and computerized physician order entry on reducing laboratory specimen misidentification errors in the emergency department. Acad Emerg Med 2005;12(Suppl 1):49.
53. Murphy MF, Kay JD. Barcode identification for transfusion safety. Curr Opin Hematol 2004;11:334-8.
54. Nichols JH, Bartholomew C, Brunton M, Cintron C, Elliott S, McGirr J, et al. Reducing medical errors through barcoding at the point of care. Clin Leadersh Manag Rev 2004;18:328-34.
55. Askeland RW, McGrane S, Levitt JS, Dane SK, Greene DL, Vandeberg JA, et al. Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. Transfusion 2008;48:1308-7.
56. Hayden RT, Patterson DJ, Jay DW, Cross C, Dotson P, Possel RE, et al. Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital. J Pediatr 2008;152:219-24.
57. Weilert M, Tilzer LL. Putting bar codes to work for improved patient care. Clin Lab Med 1991;11:227-38.
58. Li C, Wu PM, Han J, Ahn CH. A flexible polymer tube lab-chip integrated with microsensors for smart microcatheter. Biomed Microdevices 2008;10:671-9.
59. Santucci PA, Haw J, Trohman RG, Pinski SL. Interference with an implantable defibrillator by an electronic antitheft-surveillance device. N Engl J Med 1998;339:1371-4.
60. van der Togt R, van Lieshout EJ, Hensbroek R, Beinat E, Binnekade JM, Bakker PJ. Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment. J Am Med Assoc 2008;299:2884-90.
61. Oosterhuis WP, Ulenkate HJ, Goldschmidt HM. Evaluation of LabRespond, a new automated validation system for clinical laboratory test results. Clin Chem 2000;46:1811-7.
62. Wears RL, Berg M. Computer technology and clinical work: still waiting for Godot. J Am Med Assoc 2005;293:1261-3.
63. Koppel R, Metlay J, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of computerized physician order entry systems in facilitating medication errors. J Am Med Assoc 2005;293:1197-203.
64. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. J Am Med Assoc 1995;274:29-34.
65. Dzik WH. New technology for transfusion safety. Br J Haematol 2007;136:181-90.
66. Trombert-Paviot B, Couris CM, Couray-Targe S, Rodrigues JM, Colin C, Schott AM. Quality and usefulness of an anonymous unique personal identifier to link hospital stays recorded in French claims databases. Rev Epidemiol Sante Publique 2007;55:203-11.
67. Valenstein P. Patient identification accuracy. Q-Tracks (QT1) 2004 annual summary. Northfield, IL: College of American Pathologists, 2005.
68. Ricós C, Biosca C, Ibarz M, Minchinela J, Llopis MA, Perich C, et al. Quality indicators and specifications for strategic and support processes in laboratory medicine. Clin Chem Lab Med 2008;46:1189-94.